Summary

Background:

Medication reconciliation (MR) at hospital admission, transfer, and discharge has been designated as a required hospital practice to reduce adverse drug events.

Objectives:

To perform MR among elderly patients admitted to the hospital and to determine factors that influence differences between the various lists of prescribed drugs as well as their actual consumption.

Methods:

We studied patients aged 65 years and older who had been admitted to the hospital and were taking at least one prescription drug.

Results:

The medication evaluation and recording was performed within 24 hours of admission (94%). The mean number of medications was 7.8 per patients, 86% consumed 5 or more medications. Mismatching between medication prescribed by a primary care physician (PCP) and by real medication use (RMU) was found in 82% of patients. In PCP the most common mismatched medications were cardiovascular drugs (39%) followed by those affecting the alimentary tract, metabolism (24%), and the nervous (12%) system. In RMU, the most commonly mismatched medications were those affecting the alimentary tract and metabolism (36%). Among all causes of mismatched medications, discrepancies in one drug were found in 67%, in two drugs in 21%, and in three drugs in 13%. The mismatching was more common in females (85%) than in males (46%, P = 0.042).

Conclusions:

This study provided evidence in a small sample of patients on differences of drug prescription and their use on admission and on discharge from hospital. MR processes have a high potential to identify clinically important discrepancies for all patients.